Lichen sclerosus in women

Rates of self-reported urinary, gastrointestinal, and pain comorbidities in women with vulvar lichen sclerosus

OBJECTIVE

The study aimed to determine the prevalences of comorbid disorders in women with vulvar lichen sclerosus.

MATERIALS AND METHODS

A retrospective review of self-administered questionnaires regarding the health history of 308 women with lichen sclerosus seen at a vulvar clinic between 2006 and 2011 was performed. Responses to questions about urinary (overactive bladder [OAB], urinary incontinence [UI], and stress UI), gastrointestinal (inflammatory bowel diseases, constipation, and irritable bowel syndrome), thyroid dysfunction and pain (interstitial cystitis, fibromyalgia, temporomandibular joint disorder, and vulvar pain) disorders were collected. The percentage of subjects self-reporting each comorbidity was compared with the published prevalence in the general population using a single-value binomial test.

RESULTS

Subject demographics (data presented as median [range] or percentage): age, 56.4 years (20.0-92.5); body mass index, 27.5 kg/m2 (17.4-53.1); parity 2 (0-10); white, 92.9%; and biopsy proven 65.6%. Prevalences of self-reported comorbidities in our subjects are as follows: OAB, 15.3%; UI, 38.6%; stress UI, 27.9%; inflammatory bowel diseases, 1.9%; constipation, 32.5%; irritable bowel syndrome, 19.5%; thyroid dysfunction, 33.1%; interstitial cystitis, 2.6%; fibromyalgia, 9.1%; temporomandibular joint disorder, 13.0%; and vulvar pain, 83.1%. The prevalence of each disorder is significantly different from that in the general population, with all p values ≤ .02.

CONCLUSIONS

Vulvar lichen sclerosus is associated with numerous bladder, bowel, and pain comorbidities. The prevalences of all of these disorders are higher in our subjects than the general population except OAB, which we find at approximately one third of the general population. Patients with lichen sclerosus should be screened for comorbidities that may affect their health and/or quality of life.

Epstein-Barr virus and human papillomavirus infection in vulvar lichen sclerosus

OBJECTIVE

We investigated the presence of the Epstein-Barr virus (EBV) and human papillomavirus (HPV) in patients with vulvar lichen sclerosus (LS).

MATERIALS AND METHODS

We investigated the presence of HPV and EBV from 34 vulvar biopsies of patients with LS who had had no previous treatment and from 17 normal vulvar brushings used as controls. We used polymerase chain reaction to amplify DNA sequences of these viruses. Human papillomavirus and EBV DNA detection was carried out using MY09/MY11 and TC67/TC69 consensus primers, respectively. The amplified polymerase chain reaction products were analyzed by 10% polyacrylamide gel.

RESULTS

The mean age of the patients was 57 years old, with the majority postmenopausal. Human papillomavirus DNA was not found in the LS samples studied, but it was found in 23.2% (4/17) of the controls. However, EBV DNA was found in 26.5% (9/34) of the LS samples analyzed, and it was not found in the controls.

CONCLUSIONS

Our results showed no relationship between HPV and LS. This result is in accordance with the literature. We have found 26.5% of EBV in our samples. This is a preliminary study, and the follow-up of these patients will elucidate whether EBV could play a role in cases of LS.

Vulvodynia: case report and review of literature

Vulvodynia is defined as chronic vulvar burning, stinging, rawness, soreness or pain in the absence of objective clinical or laboratory findings to explain these symptoms. Vulvodynia is a chronic pain syndrome affecting up to 18% of the female population and is generally regarded as an underdiagnosed difficult to treat gynecological disorder. An increasing number of patients present with symptoms of vulvar pain, soreness, burning or irritation, which becomes chronic. Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective clinical or laboratory findings to explain these symptoms. We present a case of vulvodynia accompanying somatoform disorder and depression.

Alterations of Basement Membrane Zone and Cutaneous Microvasculature in Morphea and Extragenital Lichen Sclerosus

The aim of this study was to compare alterations of the basement membrane zone (BMZ) and to visualize changes within the skin vascular network in morphea and extragenital lichen sclerosus with the use of laser scanning confocal microscopy. This work was performed in eight plaques of morphea (three active and five inactive) and eight of lichen sclerosus (three of short duration and five long-lasting). Biopsy specimens from six healthy individuals served as controls. The biopsies were cut into 40-microm-thick sections, labeled with antibodies against beta4-intergin (a lamina lucida marker), collagen IV, and the N-terminal end of collagen VII (lamina densa markers) and C-terminal end of collagen VII (a sublamina densa marker) and studied using laser scanning confocal microscopy. Three-dimensional reconstruction of various regions of the BMZ showed a decreased number and size of the dermal papillae both in morphea and lichen sclerosus compared with normal skin. In morphea, the continuity of the BMZ at the level of lamina lucida, lamina densa, and sublamina densa was preserved whereas in LS numerous invaginations and holes were present in the BMZ at the level of the lamina lucida and lamina densa. Thus the alterations of the BMZ in morphea differ from those in lichen sclerosus. Three-dimensional reconstruction of the skin vascular network showed increased angiogenesis only in the early inflammatory stage of morphea, whereas in inactive morphea and lichen sclerosus various numbers of enlarged vessels were visible. The changes in the vascular network in morphea appear to be related to the activity of the disease.

The management of vulval pain syndromes

Vulval problems are common in gynaecological practice. Pain syndromes of the vulva should be considered once infection and dermatological causes of vulval symptoms have been excluded. This article covers vulval vestibulitis and dysaesthetic vulvodynia, the two subgroups of vulval pain syndromes.

Alterations of Basement Membrane Zone in Bullous and Non-Bullous Variants of Extragenital Lichen Sclerosus

The aim of the study was to compare alterations of various regions of the basement membrane zone (BMZ) in lichen sclerosus (LS) using laser scanning confocal microscopy. The study included three cases of bullous LS, one case of bullous LS that developed in the course of graft-versus-host disease (GVHD), and six cases of non-bullous LS. Three cases of morphea served as a control. Biopsies from patients' skin and control biopsies from normal human skin were cut into 30-microm thick slides and labeled with antibodies against beta4-intergin (lamina lucida marker), collagen IV, and the N-terminal end of collagen VII (lamina densa markers) and the C-terminal end of collagen VII (sublamina densa marker) using routine immunofluorescence (IF). Three-dimensional (3D) reconstruction of various regions of the BMZ showed a decrease in the number and size of the dermal papillae in LS and morphea as compared with normal skin. In LS numerous invaginations and holes were present in the BMZ at the level of the lamina lucida and lamina densa. Computer animation of 3D projections revealed that the thickness of the lamina densa observed under the light microscopy is an optical artifact dependent on periodical tortion of the lamina densa along its axis. Torsions and invaginations of the BMZ are equally responsible for the phenomenon of artificial reduplication of the lamina densa observed at the ultrastructural level. IF labeling with antibody against the N-terminal end of collagen VII disclosed the presence of a large hole (up to 25 microm) in the lamina densa and the presence of granular material in deep dermis suggestive of partial degradation of lamina densa at the level of anchoring fibers. An IF mapping study showed blister formation below the lamina densa in three patients with bullous LS, whereas in a case of LS associated with GVHD, a blister formed through the basal layer of the epidermis. In morphea, there was flattening of BMZ at the level of lamina lucida, lamina densa, and sublamina densa but the continuity of BMZ was preserved. Three-dimensional reconstruction of dermal-epidermal junction in LS revealed alterations of the BMZ, most pronounced at the level of the lamina densa and sublamina densa.

Linear extragenital lichen sclerosus with underlying bony atrophy

We describe a 21-year-old male patient with linear extragenital lichen sclerosus. The lesions are confined to the left side of his body and consist of 3 long bands running along the left leg and several patchy and linear lesions on the left side of his trunk. An associated finding is a smaller diameter of the distal part of his left lower leg caused by bony atrophy of the underlying portion the tibia. This is the fifth reported case of linear lichen sclerosus.

Vulvar lichen sclerosus : pathophysiology and treatment

Lichen sclerosus is a chronic disorder of the skin and mucosal surfaces, and is most commonly seen on the female genital skin. It also occurs on other areas of the body. Any age group may be affected, although it is seen more often in elderly women. The exact cause of lichen sclerosus is unknown. There have been reports of family members with lichen sclerosus; thus it may have a genetic link. There is also the possibility of an autoimmune connection. Currently, ultra-potent topical corticosteroids are the medical treatment of choice. Other treatments that have been utilized for this condition include testosterone, progesterone, tacrolimus, surgery, and phototherapy. Surgery should be reserved for symptomatic patients who fail to respond to multiple medical treatments, as there is a high recurrence rate following surgery. The risk of developing squamous cell carcinoma of the vulva approaches 5% in women with vulvar lichen sclerosus, and therefore close surveillance by the healthcare provider and patient is needed. This review discusses the history, clinical features, pathophysiology, and treatment of lichen sclerosus of the vulva, as well as pregnancy issues and sexual function in patients with this condition. In addition, problems specific to children with lichen sclerosus are reviewed.

Comparative immunophenotypic study of lichen sclerosus: epidermotropic CD57+ lymphocytes are numerous--implications for pathogenesis

To characterize the immunophenotype of inflammatory cells in lichen sclerosus (LS), we performed a comparative case control study using one- and two-color immunohistochemistry and the nitro blue tetrazolium (NBT) reaction. Study material consisted of 100 biopsies from patients with LS or from 12 control groups consisting of inflammatory, scarring, and depigmenting cutaneous disorders. In addition, fresh tissue was sampled from four vulvectomy specimens for NBT testing. The typical inflammatory infiltrate of LS contained numerous epidermotropic CD3+, CD8+, CD57+ cells, increased intraepidermal HLA-DR+ cells, and a dermal infiltrate rich in CD8+, CD57+, HLA-DR+, and CD68+ inflammatory cells. Comparing LS to the 12 control groups, epidermotropic CD57+ lymphocytes independently predicted LS (P = 0.006, logistic regression, multivariate analysis). Among the 12 control groups, only specimens of the inflammatory stage of morphea exhibited numerous dermal CD57+ lymphocytes. Two-color immunohistochemistry confirmed the CD3+/CD8+CD57+ and CD3+/ CD8+/CD57+HLA-DR+ epidermotropic and dermal lymphocytic phenotypes and the dermal macrophage CD68+HLA-DR+ phenotype. In LS, the NBT reaction revealed evidence of superoxide production associated with CD68+HLA-DR+ cells. Expansion of CD8+CD57+lymphocytes is associated with viral infections, autoimmune disease, malignancies, and transplantation and is suspected to be the result of chronic excessive antigen challenge. In these pathologic states, CD8+CD57+ lymphocytes (as terminally differentiated, antigen-specific T cells) participate in the suppression of cytolytic activity to limit tissue damage. In LS, activated macrophages and lymphocytes indicate persistent antigen-driven inflammation. LS's numerous CD8+CD57+ lymphocytes may be either the mediators or the consequence of its hallmark sclerosis.

Histologic features of lichen sclerosus et atrophicus in a surgical scar

A 76-year-old woman presented with a 7-mm, hard, pink nodule at the site of an appendectomy scar of more than 70 years' duration. The clinical impression at the time of biopsy was that of a keloid. Surprisingly, light microscopic examination revealed classic histologic features of late-stage lichen sclerosus et atrophicus (LSA) overlying a scar. Elastic tissue stain highlighted the unusual presence of abundant nodules of elastin in the reticular dermis only.